Medical Review Nurse Auditor – Home-based – Wyoming

Health Integrity, a wholly-owned subsidiary of Quality Health Strategies, Inc., is dedicated to protecting the fiscal and clinical integrity of healthcare systems in Medicare, Medicaid, and the private sector. The company operates nationally as a federally-designated program integrity contractor for the Centers for Medicare & Medicaid Services (CMS). Health Integrity’s expert clinical and technical staff identify and investigate potential fraud, waste and abuse in healthcare – aiding law enforcement agencies and protecting public resources.

Health Integrity has exciting opportunities for Medical Review Nurse Auditors to join our Cerritos, CA based Unified Program Integrity Contractors (UPIC) team. Our UPIC team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 16 Western states and territories. We’re seeking high performing candidates with a track record of succeeding in fast paced environments. Home-based positions for well-qualified candidates are available in Seattle, WA; Las Vegas, NV; Cheyenne, WY; and Sioux Falls, SD and Salt Lake City, UT. Please note: This position is contingent upon the final award of contract to Health Integrity.

The Nurse Auditor is a mid-level professional that works both independently and in a team environment that may be comprised of medical professionals, claims analysts, and auditors to perform medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed, as well as production of final review/audit report across all service and provider types, including, but not limited to, individual practitioners, institutions, and managed care entities to examine payments to providers. Where payments are not valid, establishes overpayments and initiates recoupment, revocation, or other administrative actions, as appropriate.

Essential Duties and Responsibilities include some or all of the following. Other duties may be assigned.

• Review Explanation of Benefit (EOB) cases, beneficiary, provider, and other potential overpayment, fraud, waste, and abuse.
• Completes desk review or field review/audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Effectively identifies and resolves claims issues and determines root cause.
• Interacts with beneficiaries and health plans to obtain additional case specific information, as needed.
• Consults with Subject Matter Experts for advice and clarification.
• Completes inquiry letters, investigation finding letters, and case summaries.
• Gathers necessary citations to document review/audit findings.
• Coordinates review/audit activities with appropriate staff.
• Prepares work-papers timely and places them in the appropriate files.
• Uses the quality review process effectively to ensure final review/audit reports are error free.
• Completes review/audits and auditing steps within established timeframes and using established auditing principles, proactively informing management of potential shortfalls in timeliness and quality.
• Performs research regarding Medicare and Medicaid guidelines, to be well versed about rules, regulations, and policies that will be needed to establish incorrect payments to providers and identify overpayments for recovery.
• Identifies potential fraud independently and refers matters of fraud to the CMS-MIG and law enforcement, as prescribed.
• Responsible for case-specific or plan-specific data entry and reporting.
• Participates in internal and external focus groups and other projects, as required.
• Identifies opportunities to improve processes and procedures.
• Testifies at various legal proceedings, as necessary.
• May mentor and provide guidance to junior associates.
• Performs a variety of tasks some requiring independent thought and research. A degree of creativity and latitude is required.
• Serves as a trainer or staff resource for technical and program issues.

Required Skills
To perform the job successfully, an individual should demonstrate the following competencies:

• Analytical – Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; The ability to understand complex situations and governing policies/laws and analyze large amounts of data.
• Problem Solving – Gathers and analyses information skillfully; Identifies and resolves problems.
• Judgment – Supports and explains reasoning for decisions.
• Written Communication – Writes clearly and informatively; Able to read and interpret written information.
• Quality Management – Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Interpersonal Skills – Maintains confidentiality; Ability to meet and deal with stakeholders (e.g., providers, state personnel, CMS, OIG, etc.) in a professional manner; Communicates effectively with all team members.
• Teamwork – Balances team and individual responsibilities; Exhibits objectivity and openness to others’ views; Gives and welcomes feedback; Contributes to building a positive team spirit; Supports everyone’s efforts to succeed.
• Professionalism – Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Other Skills and Abilities

• To perform this job successfully, an individual should have basic understanding of the use of the computer for entry and research and knowledge of office software and the internet to meet contract deliverables.
• Utilizes required data entry and reporting systems, including advanced features.
• Must have the ability to work independently with minimal supervision.
• Must be able to communicate effectively with all members of the team to which he/she is assigned.
• Must have the ability to grasp and adapt to changes in procedure and process.
• Must have the ability to effectively resolve complex issues.
• Ability to organize work activities in order of ever-changing priorities, ensuring that critical paths and due dates are met.
• Proactively inform management in advance of due dates and critical paths not on track to being met along with reasons why.

Required Experience

• A BSN or an RN with additional current and active degree/license/certification/s in a relevant discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA, Finance, Accounting).
• At least five years clinical experience.
• At least two years claims review experience required.
• Experience that demonstrates expertise in conducting utilization reviews, ICD-9/10 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations preferred. Certified professional coding credentials preferred (or will be required within one year of hire).
• Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred. Pre- and post-pay claims review and healthcare data experience preferred.

Certificates, Licenses, Registrations

Current, active and non-restricted RN licensure required.

Travel Requirements

Depending on contract requirements, regular travel may be required, including overnight travel, which may require use of personal/rental vehicle for travel within the region.

Health Integrity is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.